Fincen Form 107 - Registration Of Money Services Business - 2011 Page 2
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Part IV
(continued)
25 Enter the n umber of branches of the registrant.
Reminder: do not separately register each branch.
See instructions for an explanation of the term “branch”.
26 Money services business activities of the registrant. Check as many as apply
. See instructions for an explanation of t he terms ” issuer”,
“seller”, “redeemer”, “check casher”, and “money transmitter”.
a
Issuer of traveler’s checks
d
Issuer of money orders
g
Currency dealer or exchanger
e
Seller of money orders
b
Seller of traveler’s checks
h
Check casher
f
Redeemer of money orders
i
Money transmitter
c
Redeemer of traveler’s checks
27 Is any part of the registrant’s money services business an informal value transfer system?
a
Yes
b
No
See the explanation of “money transmitter” in the instructions.
28 Is any part of the registrant’s money services business conducted as a mobile operation?
a
Yes
b
No
29 Enter the number of agent s authorized to conduct each money services business activity . Do not include branches, or person s who are
solely employees. See instructions for an explanation of the term “agent”.
e Currency exchange
a Traveler’s check sales
or dealer
b Traveler’s check redemption
f Check cashing
c
Money order sales
g Money transmission
d
Money order redemption
Part V
Primary Transaction Account for MSB Activities
30 If the registrant has more than one transaction account for money services business activities check here.
See instructions for an explanation of the term “transaction account”.
The registrant’s primary transaction account is the one that has the greatest annual dollar amount of money services bus iness activity.
In items 31 through 36 enter information about the registrant’s primary transaction account for money services business
activities.
31 Name of financial institution where the primary transaction account is held
33 City
32 Address
36 Primary transaction account number
34 State
35 ZIP Code
Part VI
Location of Supporting Documentation
If the supporting documentation is kept at the U.S. location reported in Part II check here
and continue to Part VII.
37 Address
38 City
39 State
40 ZIP Code
Part VII
Authorized Signature
I am authorized to file this form on behalf of the money services business listed in Part II. I declare that the information provided is true, correct and
complete. I understand that the money services business listed in Part II is subject to the Bank Secrecy Act and its implementing regulations. See 31
CFR Part Chapter X. The money services business listed in Part II maintains a current list of all agents, an estimate of its b usiness volume in the
coming year, and all other information required to comply with 31 U.S.C. 5330 and the regulations thereunder
. The signature of the owner ,
controlling person or authorized corporate officer is mandatory .
42 Print name
41 Signature
44 Date of signature
43 Title
______ / _____ / _______
MM
DD
YYYY
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